Introduction
Fractures of the proximal humerus, commonly occurring within the shoulder girdle, are injuries that constitute a significant health problem, particularly among the elderly population with osteoporotic bones. These injuries can cause considerable pain, disability, and impact on quality of life. In 2019, a team of esteemed orthopedic specialists from various top hospitals in New Delhi, India, published vital practice guidelines addressing the management of proximal humeral fractures. These guidelines have been widely acknowledged in the Journal of Clinical Orthopaedics and Trauma. This article provides an in-depth discussion of these guidelines, their implications for patient care, and the ongoing debate on the optimal management of these fractures.
Understanding Proximal Humeral Fractures
Proximal humeral fractures involve the upper segment of the humerus bone, near the shoulder joint varying in severity from simple to multi-fragmented complex forms. Treatment often depends on the nature of the fracture and patient-specific factors.
The Guidelines for Practice
Published by Misra et al., the practice guidelines represent a systematic approach to managing proximal humeral fractures (doi: 10.1016/j.jcot.2019.04.005). They provide recommendations based on the best available evidence and expert opinion, considering operative and non-operative interventions.
Non-operative vs. Operative Management
Non-operative management often includes immobilization, physical therapy, and pain control. Operative interventions range from closed reduction with percutaneous pinning, open reduction and internal fixation (ORIF), to shoulder replacement interventions such as hemiarthroplasty or reverse shoulder arthroplasty in select cases.
The guidelines underlined that operative treatment is generally reserved for more complex fractures and those unlikely to achieve satisfactory outcomes with conservative management. However, they also caution that surgical interventions should take into account patient’s age, activity level, bone quality, and the fracture’s complexity.
A Scientific Consensus
Various studies cited within the guidelines, including those by Laux et al. (PMC5613450), Sabharwal et al. (PMC5086838), and Rabi et al. (PMC4644872), provide insight into the decision-making process. They suggest that outcomes are better when the management plan is tailored to the specific fracture type and patient’s needs.
Contemporary Research
The ProPHER trial (PMC4781052), a multicentric randomized controlled trial discussed in the guidelines, compared surgical with non-surgical treatment of these fractures, shedding light on the clinical effectiveness and cost-effectiveness. Additionally, the systematic review and meta-analysis by Handoll et al. (PMC3702764), as noted in the Cochrane Database, are instrumental in guiding treatment options and highlight the need for individualized patient care.
Chivot et al. (30348542) tackled the challenge of three- and four-part displaced proximal humeral fractures in older individuals, questioning whether reverse shoulder arthroplasty is more effective than non-surgical treatment. Their findings contribute to the nuanced discussion on managing these injuries in an aging population.
Implications and Best Practices
The implications of the practice guidelines are multifaceted. They lead to a more standardized approach to managing proximal humeral fractures, emphasizing the need for a patient-centered plan. For healthcare practitioners, awareness of these recommendations is key in making informed decisions and offering patients the best possible outcomes based on their unique circumstances.
The guidelines encourage shared decision-making between the healthcare provider and patient, considering the risks and benefits of various treatment options. In older patients, especially, the goal is to balance the desire for early mobility and pain relief with the risks associated with surgical interventions.
Conclusions
The elaborated practice guidelines for proximal humeral fractures, published by the team led by Misra et al., provide a comprehensive framework for the management of these complex injuries. They encourage clinicians to weigh the pros and cons of different treatment paths and advocate for personalized care strategies.
Despite the publication of these guidelines, the orthopedic community continues to seek the perfect balance between non-operative and operative care. Further research and randomized controlled trials are necessary to continue refining the recommended practices and evolving the treatment paradigms for the best interest of patients.
References
1. Misra, S. S., Vaishya, R., Trikha, V., & Maheshwari, J. (2019). Practice guidelines for proximal humeral fractures. Journal of Clinical Orthopaedics and Trauma, 631-633. doi: 10.1016/j.jcot.2019.04.005
2. Laux, C.J., Grubhofer, F., Werner, C.M.L., Simmen, H.P., & Osterhoff, G. (2017). Current concepts in locking plate fixation of proximal humeral fractures. Journal of Orthopaedic Surgery and Research, 12, 137-145. PMC5613450
3. Sabharwal, S., Patel, N.K., Griffiths, D., Athanasiou, T., Gupte, C.M., & Reilly, P. (2016). Trials based on specific fracture configuration and surgical procedures likely to be more relevant for decision-making in the management of fractures of the proximal humerus. Bone Joint Research, 5(10), 470-480. PMC5086838
4. Rabi, S., Evaniew, N., Sprague, S.A., Bhandari, M., & Slobogean, G.P. (2015). Operative vs. non-operative management of displaced proximal humeral fractures in the elderly: A systematic review and meta-analysis of randomized controlled trials. World Journal of Orthopedics, 6(10), 838-846. PMC4644872
5. Handoll, H., Brealey, S., & Rangan, A. (2015). The ProPHER (PROximal Fractures of the Humerus: evaluation by Randomisation) trial – a pragmatic multicentric randomized controlled trial evaluating the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment of proximal fracture of the humerus in adults. Health Technology Assessment, 19(24). PMC4781052
Keywords
1. Proximal Humeral Fractures Treatment
2. Shoulder Injury Management
3. ORIF Shoulder Guidelines
4. Osteoporosis Fracture Solutions
5. Orthopedic Surgery Best Practices